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This article describes evaluation and treatment considerations for Essex-Lopresti injuries. Specific information about pattern recognition and treatment options is provided.

The rates of methicillin-resistant infections in the hand and upper extremity approach 50% in many facilities. In addition, multidrug resistance is beginning to include clindamycin. This article discusses the history, prevalence, and treatment of both community-acquired and health care-associated methicillin-resistant Staphylococcus aureus in regard to hand infections.

Trapeziometacarpal osteoarthritis is a common problem, due to the anatomy of the first ray and the forces applied to the trapeziometacarpal joint throughout activities of daily living. Numerous treatment options exist, and continue to be developed, for this problem. The current goal is to eliminate pain and restore function and strength in a timely manner. New advances allow for earlier return to function with minimally invasive techniques. Arthroscopic hemitrapeziectomy combined with interposition arthroplasty and/or suspensionplasty is a treatment option for Stage II and III trapeziometacarpal arthritis that uses a minimally invasive technique and allows for earlier return of function.

This article attempts to outline the most current relevant literature regarding diagnosis, pathoanatomy, and treatment options for complex elbow instability. Specific attention is directed toward unique injury patterns, important biomechanical principles, and recent clinical outcome studies. Directions for future research are suggested.

Cubital tunnel syndrome is a common but complicated ulnar neuropathy that needs to be carefully evaluated and classified before developing a cohesive plan of attack. In situ decompression/with medial epicondylectomy (ISD/ME) can be a viable treatment option for all preoperative grades of cubital tunnel syndrome, but may not necessarily be the treatment of choice, based on information gathered from the patient's preoperative evaluation. We outline a comprehensive list of indications for treatment of cubital tunnel syndrome by ISD/ME. If one adheres to these indications, and abides by the technique of a partial medial epicondylar excision, as advocated by O'Driscoll, Amako, and others, the results indicate that patients should have an acceptable outcome.

In this article we describe the fundamental concepts that were established by Essex-Lopresti over 50 years ago and explore the current concepts in anatomy, biomechanics, diagnosis, and treatment for longitudinal radioulnar dissociation. Moreover, we present encouraging results for treating chronic injuries to the IOM achieved by bone-ligament-bone (BLB) reconstruction using a patellar tendon graft, giving hope for this seemingly unforgiving injury. A treatment algorithm is also provided to aid in the management of acute and chronic longitudinal radioulnar dissociation.

The athlete with an LT injury typically presents with ulnar-sided wrist pain after a high-energy impaction of the wrist. Reagan's LT ballottement test and Kleinman's shear test help the examiner identify these injuries. A thorough radiographic examination includes standard PA and lateral radiographs. Magnetic resonance imaging or arthrography can be performed, but the sensitivity of these imaging studies varies. The palmar portion of the LT interosseous ligament, dorsal radiocarpal ligament, and dorsal intercarpal ligament play the most significant roles in LT stability. Lunotriquetral injuries without instability respond well to immobilization. Arthroscopy is valuable in staging and determining treatment but requires a thorough radiocarpal and midcarpal examination. Acute LT injuries with instability are treated with arthroscopic-assisted reduction and pinning. If desired, this procedure can be incorporated with an open ligament repair through a volar approach. Chronic LT tears without instability can also be treated arthroscopically. Treatment of the chronic LT tear with instability depends on the degree of collapse. Treatment in the athlete includes ligament reconstruction with capsulodesis or, rarely, intercarpal LT arthrodesis.

Subcutaneous transposition of the ulnar nerve has been widely reported as a successful surgical treatment for ulnar neuropathy at the elbow attributable to a variety of causes. Accepted indications for anterior transposition include any anatomic lesion that interferes with or impinges on the nerve along its native course. This may include a tumor, ganglion, osteophyte, valgus deformity or instability, or subluxation of the nerve, as listed previously. The surgical technique of ASCT also was described thoroughly earlier in this article. Points that warrant emphasis include thorough decompression along the entire course of the nerve, an attempt to preserve the venous plexus that accompanies the nerve, identification and preservation of branches of the medial antebrachial cutaneous nerve, and resection of a 3 to 6 cm segment of the medial intramuscular septum. Poor prognostic indicators include age over 50 years; relatively advanced neuropathy, as noted by electrical evidence of demyelination; or aggravating medical conditions, such as diabetes or alcoholism. Complications include neuroma of the medial antebrachial cutaneous nerve and resubluxation posterior to the medial epicondyle. In cases of reoperation for recurrent or persistent symptoms, inadequate release, most commonly at the medial intramuscular septum, was sited as the cause of failure in over 90% of cases. In a few cases, compression was found at the site of a fasciodermal sling. The majority of complications therefore were technical in nature and probably could have been avoided by strict attention to basic principles. Controversy surrounds the appropriate treatment for approximately half of patients in whom no clearly definable cause can be found. These cases are either attributed to "repetitive strain" or lumped into the "idiopathic" category. The pathophysiology leading to neuropathy in these groups is poorly understood, so the rationale for choosing one surgical procedure over another remains somewhat obscure. In the absence of an anatomic lesion, proponents of in situ decompression believe transposition involves unnecessary dissection, with attendant risks of devasularization or injury to the nerve or surrounding structures. Advocates of ASCT point out that the nerve may be compressed at any of several points along its course, as outlined in Fig. 1. Unlike in situ decompression, therefore, a properly performed anterior transposition assures adequate decompression at all points along its course. Indications for subcutaneous versus submuscular transposition are even less clear. Some believe submuscular transposition should be performed for more severe neuropathy, when muscular atrophy is present. Other authors point out that thin patients will be susceptible to repeated minor trauma if the nerve is left in a subcutaneous position. Neither of these contentions is supported consistently by available published data. In most cases of failed subcutaneous transposition, submuscular transposition has been used as a salvage procedure simply to place the nerve in an unscarred bed. Answers to the unresolved issues await well-designed studies. Nevertheless, there is ample cause for optimism given that adherence to basic principles has resulted in satisfactory results for 85% to 95% of patients regardless of the procedure chosen.

Disruption of the lunatotriquetral ligament is a common cause of ulnar-sided wrist pain. A review of the literature of the pathophysiology and treatment of LT ligament tears is presented. The authors report a series of 20 consecutive patients with arthroscopically confirmed LT ligament tears without a VISI collapse treated with arthroscopic reduction and pinning of the LT joint. At an average follow-up of 2 years 8 months, there was an 80% success rate. Success of the procedure correlated negatively with arthroscopic findings of chondromalacia and positively with decreased postoperative active wrist motion.

In summary, arthroscopic resection is a reasonable approach for operative treatment of the dorsal ganglion. Arthroscopy is safe and addresses the key anatomic pathology. Recurrences to date have been equal to or less than with the open technique. Arthroscopic resection minimizes the surgical scar. Arthroscopy also permits evaluation of any intra-articular pathologic condition of either midcarpal or radiocarpal joints. In our series, 42% of patients had intra-articular pathologic conditions. In this study, these findings were recorded but not treated. Symptom resolution, therefore, correlated with ganglion resection and not with intra-articular pathologic conditions. We look forward to publishing our data in full at the completion of our study.

Carpal tunnel release has a high rate of success when the open or endoscopic technique is used. The reported complications of the endoscopic procedure have included incomplete release of the transverse carpal ligament and injury to the neurovascular structures or flexor tendons. The complication rates are comparable when performed by surgeons well versed in the technique. The procedure is technically demanding but can be performed safely with an understanding of the anatomic structures at risk and strict adherence to surgical methods. The technique has a steep learning curve and requires considerable practice on cadaveric specimens after attendance at one of the available courses.

This article reviews the history of total wrist arthroplasty as a treatment option for painful, nonfunctional wrists in disease states. Technologic advances in materials, wear properties, and manufacturing now account for increased implant longevity. They may also improve total wrist replacement design, survival, and hence patient function. Also, alternative surgical treatments such as distal radius hemiarthroplasty may serve as a treatment option for patients with higher activity levels and diffuse arthritis. With careful patient selection, soft tissue considerations, and novel implant designs, TWA may become a viable treatment staple for patients with functional wrist disability.

The triangular fibrocartilage complex is a complex anatomic structure located at the ulnar aspect of the wrist and is important to the stability and biomechanical function of the ulnar carpus and distal radioulnar joint. This article will review the anatomy and biomechanical function of the TFCC and its relationship to the diagnosis and treatment of traumatic injuries to the TFCC.

Release of the transverse carpal ligament is commonly performed and highly successful in the treatment of carpal tunnel syndrome; however, complications do occur and may be broadly classified as errors in diagnosis and surgical technique. Complications range from incomplete division of the transverse carpal ligament to adherence of the flexor tendons. Awareness of possible coexistent diagnoses and treatment complications is important in avoiding and managing complications.

Injury to the interosseous membrane of the forearm typically occurs in conjunction with disruption of the radial head and the distal radioulnar joint. Frequently, the true extent of injury is not initially appreciated, and patients may develop longitudinal instability of the forearm, with wrist pain, forearm discomfort, and instability. This article outlines various treatment strategies, which include considerations at the wrist, forearm, and elbow.

Understanding the anatomy and response to injury of the peripheral nerve is important for the surgeon treating peripheral nerve injuries. Appropriate treatment also requires proper classification of the injury. Although great advances have been made in the area of microsurgical repair, results remain unpredictable. Future work in the areas of immunology, nerve conduits, and growth factors will, it is hoped, provide further information to allow for better functional recovery.

The TFCC bears axially applied load and stabilizes the distal radioulnar joint. Palmer's classification of TFCC lesions into traumatic and degenerative injuries allows a rational approach to treatment. Wrist arthroscopy provides both diagnostic and therapeutic capabilities in the treatment of these lesions.

Degenerative joint disease affecting the thumb metacarpophalangeal and interphalangeal joints is a debilitating condition, which can significantly restrict activities of daily living. Conservative measures to address symptoms include oral anti-inflammatory medications, activity modification and splinting, and intraarticular corticosteroid injections. Surgical interventions include arthroscopic synovectomy, arthroplasty, and finally arthrodesis of the affected articulations. Although short-term results from synovectomy and arthroplasty seem promising, long-term data are not yet available. Arthrodesis of the metacarpophalangeal and interphalangeal joints yields a stable yet functional thumb with reliably good pain relief.

An appreciation of the clinicopathologic presentation of children with radial dysplasia (radial club hand) is important. Management decisions depend upon the degree of radial ray defect present; in most cases these are surgical. Current surgical options favor centralization without resection of carpal bones, stabilized by tendon transfers. When the thumb ray is deficient, pollicization is a rewarding procedure.

Many factors influence the development of CTS; therefore, nonoperative treatment should not be limited to only one intervention. Nonoperative treatment is most effective in the early stages, prior to irreparable damage to the nerve. Early intervention combined with a comprehensive treatment plan can help improve effectiveness of treatment during this phase. We do not endorse any one particular conservative treatment/program as the solution for CTS, but our purpose is to explore potential options. Further study is needed to determine the most beneficial and cost-effective treatments.

The athlete with an LT injury typically presents with ulnar-sided wrist pain after a high-energy impaction of the wrist. Reagan's LT ballottement test and Kleinman's shear test help the examiner identify these injuries. A thorough radiographic examination includes standard PA and lateral radiographs. Magnetic resonance imaging or arthrography can be performed, but the sensitivity of these imaging studies varies. The palmar portion of the LT interosseous ligament, dorsal radiocarpal ligament, and dorsal intercarpal ligament play the most significant roles in LT stability. Lunotriquetral injuries without instability respond well to immobilization. Arthroscopy is valuable in staging and determining treatment but requires a thorough radiocarpal and midcarpal examination. Acute LT injuries with instability are treated with arthroscopic-assisted reduction and pinning. If desired, this procedure can be incorporated with an open ligament repair through a volar approach. Chronic LT tears without instability can also be treated arthroscopically. Treatment of the chronic LT tear with instability depends on the degree of collapse. Treatment in the athlete includes ligament reconstruction with capsulodesis or, rarely, intercarpal LT arthrodesis.

Subcutaneous transposition of the ulnar nerve has been widely reported as a successful surgical treatment for ulnar neuropathy at the elbow attributable to a variety of causes. Accepted indications for anterior transposition include any anatomic lesion that interferes with or impinges on the nerve along its native course. This may include a tumor, ganglion, osteophyte, valgus deformity or instability, or subluxation of the nerve, as listed previously. The surgical technique of ASCT also was described thoroughly earlier in this article. Points that warrant emphasis include thorough decompression along the entire course of the nerve, an attempt to preserve the venous plexus that accompanies the nerve, identification and preservation of branches of the medial antebrachial cutaneous nerve, and resection of a 3 to 6 cm segment of the medial intramuscular septum. Poor prognostic indicators include age over 50 years; relatively advanced neuropathy, as noted by electrical evidence of demyelination; or aggravating medical conditions, such as diabetes or alcoholism. Complications include neuroma of the medial antebrachial cutaneous nerve and resubluxation posterior to the medial epicondyle. In cases of reoperation for recurrent or persistent symptoms, inadequate release, most commonly at the medial intramuscular septum, was sited as the cause of failure in over 90% of cases. In a few cases, compression was found at the site of a fasciodermal sling. The majority of complications therefore were technical in nature and probably could have been avoided by strict attention to basic principles. Controversy surrounds the appropriate treatment for approximately half of patients in whom no clearly definable cause can be found. These cases are either attributed to "repetitive strain" or lumped into the "idiopathic" category. The pathophysiology leading to neuropathy in these groups is poorly understood, so the rationale for choosing one surgical procedure over another remains somewhat obscure. In the absence of an anatomic lesion, proponents of in situ decompression believe transposition involves unnecessary dissection, with attendant risks of devasularization or injury to the nerve or surrounding structures. Advocates of ASCT point out that the nerve may be compressed at any of several points along its course, as outlined in Fig. 1. Unlike in situ decompression, therefore, a properly performed anterior transposition assures adequate decompression at all points along its course. Indications for subcutaneous versus submuscular transposition are even less clear. Some believe submuscular transposition should be performed for more severe neuropathy, when muscular atrophy is present. Other authors point out that thin patients will be susceptible to repeated minor trauma if the nerve is left in a subcutaneous position. Neither of these contentions is supported consistently by available published data. In most cases of failed subcutaneous transposition, submuscular transposition has been used as a salvage procedure simply to place the nerve in an unscarred bed. Answers to the unresolved issues await well-designed studies. Nevertheless, there is ample cause for optimism given that adherence to basic principles has resulted in satisfactory results for 85% to 95% of patients regardless of the procedure chosen.

Carpal tunnel release has a high rate of success when the open or endoscopic technique is used. The reported complications of the endoscopic procedure have included incomplete release of the transverse carpal ligament and injury to the neurovascular structures or flexor tendons. The complication rates are comparable when performed by surgeons well versed in the technique. The procedure is technically demanding but can be performed safely with an understanding of the anatomic structures at risk and strict adherence to surgical methods. The technique has a steep learning curve and requires considerable practice on cadaveric specimens after attendance at one of the available courses.

In summary, arthroscopic resection is a reasonable approach for operative treatment of the dorsal ganglion. Arthroscopy is safe and addresses the key anatomic pathology. Recurrences to date have been equal to or less than with the open technique. Arthroscopic resection minimizes the surgical scar. Arthroscopy also permits evaluation of any intra-articular pathologic condition of either midcarpal or radiocarpal joints. In our series, 42% of patients had intra-articular pathologic conditions. In this study, these findings were recorded but not treated. Symptom resolution, therefore, correlated with ganglion resection and not with intra-articular pathologic conditions. We look forward to publishing our data in full at the completion of our study.

Disruption of the lunatotriquetral ligament is a common cause of ulnar-sided wrist pain. A review of the literature of the pathophysiology and treatment of LT ligament tears is presented. The authors report a series of 20 consecutive patients with arthroscopically confirmed LT ligament tears without a VISI collapse treated with arthroscopic reduction and pinning of the LT joint. At an average follow-up of 2 years 8 months, there was an 80% success rate. Success of the procedure correlated negatively with arthroscopic findings of chondromalacia and positively with decreased postoperative active wrist motion.

The triangular fibrocartilage complex is a complex anatomic structure located at the ulnar aspect of the wrist and is important to the stability and biomechanical function of the ulnar carpus and distal radioulnar joint. This article will review the anatomy and biomechanical function of the TFCC and its relationship to the diagnosis and treatment of traumatic injuries to the TFCC.

Release of the transverse carpal ligament is commonly performed and highly successful in the treatment of carpal tunnel syndrome; however, complications do occur and may be broadly classified as errors in diagnosis and surgical technique. Complications range from incomplete division of the transverse carpal ligament to adherence of the flexor tendons. Awareness of possible coexistent diagnoses and treatment complications is important in avoiding and managing complications.

The TFCC bears axially applied load and stabilizes the distal radioulnar joint. Palmer's classification of TFCC lesions into traumatic and degenerative injuries allows a rational approach to treatment. Wrist arthroscopy provides both diagnostic and therapeutic capabilities in the treatment of these lesions.